Archive for the ‘healthcare’ Category

The Eldercare Locator is a service of the U.S. Administration on Aging. It’s been around for nearly 20 years. Its toll free number is 800-677-1116. Its website is http://www.eldercare.gov. It provides information about long-term care alternatives, transportation options, caregiver issues and government benefit eligibility. This information is also available in Spanish and other languages. There is an extensive database of links, publications, and other resources.

I have heard, all to frequently, about people losing Medicare coverage for skilled nursing care because it had been determined that they had reached a “healing plateau.” That is, they were not improving from the skilled nursing care they were receiving (and would not improve from additional skilled care) and, therefore, were deemed to be only receiving “custodial care”, not the skilled nursing services required for Medicare benefits.

While that may have been the standard in the past, it is not the standard today, but it still comes up. As it did recently, when a federal judge ruled against the Social Security Administration and rejected “Improvement” as a criterion for continuing Medicare skilled nursing facility (SNF) coverage. Here is a summary of the case.

A federal district ruled that an administrative law judge (ALJ) with the U. S. Centers for Medicare & Medicaid Services (CMS) improperly denied Medicare benefits to a patient in a skilled nursing facility. The ALJ had concluded that “[i]t became apparent that no matter how much more therapy the Beneficiary received, she was not going to achieve a higher level of function.”

After undergoing hip replacement surgery on April 28, 2008, Mary Beth Papciak, 81, developed a urinary tract infection and was readmitted to the hospital. On June 3, 2008, Ms. Papciak was discharged by Dr. Tuchinda to ManorCare to receive skilled nursing care, physical therapy and occupational therapy. Upon Ms. Papciak’s admission to ManorCare, Ms. Papciak was unable to ambulate and could not use her walker due to numbness of her hands due to what was later diagnosed as carpal tunnel syndrome. Ms. Papciak also had a history of cellulitis, anemia, cholecystectomy, chronic atrial fibrillation, hypertension, anxiety and depression.

Ms. Papciak received therapy five days a week; however, she made slow progress during her stay. Her therapy included physical and occupational therapy, treatment, self care, therapeutic exercises and therapeutic activities. Her initial treatment was primarily for ambulation. Medicare paid for the skilled care Ms. Papciak received from June 3 through July 9, 2008. It was determined, however, that effective July 10, 2008, Ms. Papciak no longer needed skilled care because Ms. Papciak had made only minimal progress in some areas, had regressed in other areas, and had been determined to have met her maximum potential for her physical and occupational therapy. As a result, Medicare denied payment from July 10 through July 19 because Ms. Papciak was only receiving “custodial care,” not the skilled nursing services required for Medicare coverage.

Ms. Papciak appealed the decision denying coverage, and her appeal worked its way up the chain to an administrative law judge, which upheld the denial, which was then upheld by CMS’s Medicare Appeal Counsel (MAC). After exhausting her administrative remedies, Ms. Papciak sought relief in federal district court.

The federal district court sided with Ms. Papciak. The proper legal standard to be applied to a patient entitled to Medicare benefits in a skilled nursing facility is whether the patient needs skilled services to enable her to maintain her level of functioning.

In the CMS Medicare Skilled Nursing Facility Manual which sets forth the standard to be applied, the reviewing authorities must give consideration to a patient’s need for skilled nursing care in order to maintain her level of functioning. The relevant portion reads: “The services must be provided with the expectation, based on the assessment made by the physician of the patient’s restoration potential, that the condition of the patient will improve materially in a reasonable and generally predictable period of time, or the services must be necessary for the establishment of a safe and effective maintenance program.”

Neither the ALJ nor the MAC addressed Ms. Papciak’s need for skilled nursing care in order to maintain her level of functioning. This was error, held federal Magistrate Judge Cathy Bissoon, requiring that the decision to deny her benefits be overturned.

The ALJ had concluded that “[i]t became apparent that no matter how much more therapy the Beneficiary received, she was not going to achieve a higher level of function.” Similarly, the MAC stated that “[d]espite the appellant’s arguments to the contrary, the enrollee made little or no progress in therapy from the time of her admission to ManorCare through her discharge from skilled care on or around July 10, 2008.”

This is a common misunderstanding about Medicare’s skilled nursing facility benefit, that the patient must be showing “progress” in order for Medicare to pay for her care. Indeed, federal regulations state that “[t]he restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.”

What happened to Ms. Papciak? She was hospitalized again, discharged to a different skilled nursing facility, where she received physical and occupational therapy under the Medicare benefit, and was discharged home on August 21, 2008.

In the coming year, seniors will see some of the biggest changes to Medicare Part D since the prescription benefit became available in 2006. More than 17 million are enrolled in private drug plans offered through Medicare.

The program’s benefits will improve for those who land in the program’s prescription drug coverage gap, the so-called donut hole. It has been announced that the nation’s pharmaceutical manufacturers will provide 50 percent discounts on the cost of the covered brand-name prescription drugs for beneficiaries in the Medicare Part D coverage gap starting in 2011.

Benefits of the Affordable Care Act for seniors include the provisions in the law that help fight fraud and make certain preventive care and annual wellness exams remain free for most Medicare beneficiaries.

The average 2011 Medicare prescription drug plan premium will remain similar to rates beneficiaries are currently paying – an increase of $1. Most Medicare prescription drug plan premiums will remain stable next year and beneficiaries will find there are clearer plan options, including many plans that can help them save even more. They will find that the Affordable Care Act improves the value of drug coverage they get next year.

Recent studies indicate that approximately 43.5 million Americans look after someone age 50 or older. It is not known how many are paid for doing so, but the numbers are rising. If that caregiver is a family member, it’s important to draft a formal employment agreement – and disclose the arrangement to the entire family.

Employment agreements should document a caregiver’s responsibilities and hours, and set a rate of pay that’s in line with local practices. Both the caregiver and care recipient should sign the contract and disclose it to the rest of the family to avoid causing family tension or running afoul of Medicaid eligibility requirements.

If a parent will rely on Medicaid to cover future nursing-home costs, a family must pay the caregiver in a way that’s permitted under Medicaid law. Before Medicaid will pick up the tab for nursing-home costs, it requires applicants to recoup certain payments made to relatives over the previous five years to pay the nursing home.

But if payments to relatives are made under the terms of a written employment agreement, often called a personal-care contract, the law allows it as long as the contract was in place before the services are rendered.

“A person is always startled when he hears himself called old for the first time.”
— Oliver Wendell Holmes

Coping with changes that affect an older person’s independence isn’t easy. An article I read recently in USA Weekend offered these tips to help with the difficult conversations you may need to have with your older parent, spouse, sibling, or other relative:

Giving up the car keys
• Get an evaluation. Most states let anyone report an at-risk driver. Most also have an evaluation process to determine whether seniors are a danger to themselves or others. Often, people whose driving skills don’t pass muster will stop driving because they realize they’re no longer up to it.
• Be direct. Telling a parent that he or she has to give up driving can be difficult, but important. It’s one thing if you kill yourself, but what if you kill somebody else? That thought may get the at-risk driver to stop.
• Involve the doctor. If a physician reports an at-risk driver, the driver must, at minimum, take another road test.
• Arrange alternatives. Set up transportation alternatives before a parent stops driving. Set up home delivery for groceries.

Moving to assisted living
• Put yourself in the senior’s shoes. Frame the discussion from the elderly person’s point of view. For many, the pinnacle achievement in life was to buy a house, pay it off with the idea of living in it forever. It’s not just a house, it’s history and memories.
• Try it out. Many major assisted-living companies offer respite visits. Seniors can stay a week or two to try it out, and then go home.
• Don’t sell — yet. Wait to sell the house until the senior is comfortable in assisted living. If you need to sell right away, move the senior first. In this market most houses aren’t going to sell right away, and if assisted living doesn’t work out, you can always take the house off the market.
• Be patient. Satisfaction rates in assisted living are in the 80 to 90 percent once the resident is settled in. Allow three to four months for seniors to accept the change.

Handling finances
• Understand the senior’s point of view. Today’s seniors are the generation of savers. It’s hard to give control of their money to a younger person who doesn’t have the same view of saving and spending. Show that you understand your loved one’s point of view and offer reassurance that his or her wishes will be honored.
• Be tactful with suggestions. Be sensitive to the senior’s tolerances. Automatic bill-paying and online banking may seem ideal to you, but some elderly people don’t like the idea of giving access to their bank account to anyone. Explain how you use these tools. Walk your loved one through the process.

A growing number of American adults and children have complex medical conditions like heart disease and diabetes. They may have drug or food allergies, suffer from disorders like autism, or take medications that medical staff should know about in an emergency. Anyone with a medical condition that would not be obvious to medics or doctors if they were unable to communicate should consider some form of medical-identification program.

An informative article on the subject was published recently in the Wall Street Journal.

New bracelets and other medical-identification systems can provide first responders with a patient’s health history. They can steer first responders to a secure website or toll-free phone number, or initiate a text message, to get the medical and prescription history of a patient who may be unconscious or unable to talk about their condition.

For some, wearing the traditional metal medical-alert bracelets is an unappealing option, and too visible a reminder of a disease or condition. That’s one reason a number of jewelry companies (including Tiffany & Co.) make bracelets, necklaces and watches. There are also pendants that can easily be hidden under clothes.

This jewelry needs to be linked to a medical-information service, such as the nonprofit MedicAlert Foundation, or emergency responders’ knowledge will be limited to what’s engraved on the accessory. People who don’t want to wear jewelry can carry a specially marked USB flash drive loaded with emergency data that medics can read from any computer in an emergency. Whatever identification system is chosen, doctors say, it should provide a way for responders to quickly access as much information as possible.

Many patients have conditions that are much more complex than can be noted on a bracelet. Last year Permanente Medical Group began offering members a $5 flash drive loaded with personal information that can be regularly updated from their electronic medical-records system. Privacy is a concern to some people, so the file is encrypted and password-protected when the patient’s data is loaded onto a flash drive.

Bracelets issued by MedicAlert are engraved with a patient’s member number and a toll-free number to access a 24/7 hot line for information. The service costs adults $39.95 for the first year and $30 annually after that. Fees for children are less. MedicAlert has also added services like notifying family members in an emergency.

For people whose doctors don’t keep electronic medical records, companies like MedInfoChip sell software programs for about $50 that help consumers set up their own health records on a computer and load them onto a USB device. American Medical ID offers a flash drive in a dog-tag style pendant for $44.95 that can be engraved with basic medical information and loaded with a patient’s medical records.

Another program, called Invisible Bracelet, does away with the need to wear a bracelet or carry a device. The program, a partnership between Docvia LLC and the American Ambulance Association, allows members to upload personal medical data to a secure website and receive a personal identification number for $10 a year. Members get cards, key fobs and stickers that show their identification number and the website address. The program is currently available in a dozen markets and is expected to expand. Docvia trains ambulance medics to use the system. The website also allows medics to automatically generate text or email messages to designated family members notifying them where the patient is being taken by ambulance.

We partner with DocuBank, which provides hospitals with access to your healthcare directives and emergency information, 24/7/365. We offer DocuBank as part of our client service package to ensure that your living will, health care power of attorney, contact information, and important medical information regarding allergies and drugs will be available when needed. We advise clients to carry their DocuBank Emergency Access Card in their wallet — next to their driver’s license or health insurance card — at all times.

End-of-life care, including hospice, was the topic of my last post. Today I want to share an article I found on jsonline.com that focuses on palliative care and its surprising benefits. A study done at Massachusetts General Hospital in Boston found that terminal lung cancer patients who started immediately on palliative care along with usual cancer care lived nearly three months longer than people given only standard cancer care, even when the second group had more chemotherapy.

One of the most common misconceptions about palliative care is that it means treatment has failed and the patient is giving up. In fact, palliative care is meant to help the gravely ill make the most of the time they have left. It typically involves a variety of caregivers who specialize in pain control and treating symptoms (such as nausea) that affect quality of life. It is not the same as hospice when doctors think a patient has less than six months to live and treating the illness no longer helps.

The study involved 151 people newly diagnosed with cancer that had spread beyond the lung. All received routine cancer care and about half also got palliative care. More than half of those on standard care alone received chemo in their last two weeks of life. Only a third of the palliative care patients did. Yet the palliative care group’s median survival was more than 11 months versus less than nine months for the group receiving standard care.

Quality of life and physical functioning improved in the palliative care group and worsened in the others. Depression was less than half as common in the palliative care group.

Doctors say when people feel better, they are much more likely to go for treatment and take better care of themselves, and that affects survival. This study shows that palliative care should be a routine part of managing any serious illness.

What should medicine do when it can’t save your life? When do you stop medical interventions and focus on improving the final days of life?

Dr. Atul Gawande began researching hospice and end-of-life care options because he didn’t know how to broach the subject of death with his terminally ill patients. He says medical professionals need to build a system that focuses on how to help dying patients achieve what’s most important to them at the end of their lives.

In an interview with Fresh Air’s Terry Gross, the surgeon and New Yorker staff writer talks about the importance of having these discussions with loved ones before a crisis comes.

In the general scheme of life, parents look after the children. But as parents age, the tables can turn. New technology is making it possible for adult children to closely monitor the daily movements and habits of their aging parents. The goal is to provide enough supervision to make it possible for elderly people to stay in their homes, which may be an emotionally and financially desirable alternative to moving to an assisted-living facility or nursing home.

Many of the systems are godsends for families. But, as with any parent-child relationship, loving intentions can be tempered by issues of control, role-reversal, guilt and a little deception. Just as the current population of adults in their 30s and 40s have a reputation of being hyper-involved, hovering parents to their own children, they now have the tools to micro-manage their aging parents.

You need to ask if this is something the parent wants. Monitoring technology for elderly people has been compared to the infamous “nanny cams,” hidden cameras some parents use to spy on their children’s babysitters. Needless to say, this can be very offensive to some.
Two recent articles, one from The New York Times and one from The Washington Post, explore some of the options available to families with aging relatives.

One choice is a GrandCare system, produced by a company of the same name based in West Bend, Wisconsin. It allows families to place movement sensors throughout a house. Information such as when doors are opened, what time a person gets into and out of bed, whether there’s been any movement in a room for a certain time period is sent out via e-mail, text message or voice mail. Costs vary depending on the features chosen, but this version costs about $8,000 to install plus monthly fees of about $75. That’s comparable to the cost of two months at an assisted-living facility.

Another monitoring alternative is a medication management system called MedMinder. It is basically a computerized pillbox. The parent’s correct daily dosages of different medications are arranged in boxes (usually by a nurse or other care provider). When it is time to take them, the pillbox beeps and flashes. If they are taken, you get a phone call or e-mail saying, essentially, Mom (or Dad) took her pills. If the pills aren’t taken within a two-hour window, the system starts nagging. It calls her. It flashes and beeps. Then you get a phone call with a message saying your mother missed her dose.

A small Virginia firm has unveiled a prototype of a portable, high-tech dwelling that would provide temporary shelter for a sick or elderly relative in the family’s back yard. It was created as an alternative to nursing homes as 78 million baby boomers head toward retirement. The company envisions that families could purchase or lease a MedCottage and set it up on their property, hooking it up to their home’s electrical and water supplies like an RV.

The N2Care MedCottage is a 12-by-24-foot prototype filled with biometric technology that would allow a family and health-care providers to monitor the condition of an aging or disabled relative. The cottage contains air-filtration systems, video links, devices that allow the remote monitoring of vital signs and sensors that could detect an occupant’s fall.

Local zoning laws may pose one of the biggest obstacles to making such dwellings a practical solution to caring for aging family members in what it calls “accessory dwelling units.” Detractors have dubbed the concept the “granny pod” and predicted that it could create conflicts between neighbors who find the dwellings unsightly.

The MedCottage has some of the features AARP advocates in accessory dwelling units, but not all of the features that could be useful for people of all ages. It’s a step in the right direction. Other companies seeking to make similar structures are Seattle-based FabCab (whose name comes from Fabulous Cabin), and San Francisco-based Larson Shores Architects, which designs what it calls Architectural Solutions for the Aging Population, or ASAP.

Several studies have been undertaken to see just where the line between loving watchfulness and over-intrusion might be drawn. People don’t want to feel their privacy is compromised, and they tend to draw the line at cameras. The key seems to be control. The older person is much more amenable if he or she can control what information is available and who can access it. Ultimately, the decision must be made by the aging parent.

When an older relative starts to need help to get through the day, many families want to avoid institutions. To keep their loved one at home, they need to either hire a home-care aide or become one.

There are two main kinds of in-home care. Personal or home-care aides provide companionship and support a person’s activities of daily living such as dressing, bathing, preparing meals and doing laundry. Home health aides may do all those things plus tasks such as administering medication or recording changes in a client’s condition. They also may work under a nurse’s supervision.

Here are questions to ask when thinking of hiring or becoming a caregiver.

What kind of care do you need and can you afford?
Before looking for a home-care worker, families need to make sure they can afford to hire one. Families typically pay for these services out of pocket unless the older person meets Medicare’s coverage conditions or has a private long-term care insurance policy that covers such needs.

If you don’t know what kind of care is needed, a specially trained geriatric care manager can help. Assessments cost about $500 to $800 depending where you live. The Alzheimer’s Association offers assistance with an always-open phone line at (800) 272-3900 and at www.Alz.org/carefinder. Medicare’s website has a Home Health Compare tool.

Rates from $14 to $22 an hour for non-medical in-home care are typical, but keep in mind that assisted-living facilities can run $2,800 to $4,400 a month. Agencies’ rates often are toward the top of the scale. Caregivers who work independently tend to be less expensive.

Should you hire an independent worker directly or go to an agency?
The advantage of using an agency is that it takes responsibility for paying wages, taxes and insurance. Agencies also run criminal background and driving-record checks, and provide back-up aides should the main caregiver get sick or go on vacation.

Families who decide to hire someone on their own should make sure they follow all state and federal employment laws, including any provisions for overtime pay. You don’t want someone going after your estate or the family member’s estate because something wasn’t handled correctly.

How do you find the right home-care aide for your needs?
Experts recommend interviewing at least six candidates. Families should interview applicants in the home so the aides know in what kind of environment they would be working. For example, having a smoker or pets in the home may be an issue. And don’t forget to include the elder’s input. Finally, don’t balk if someone who stands out is a little more expensive. Paying a little more for someone you really like is worth the extra cost.

Do you have a plan to take care of yourself?
If you’re caring for a loved one yourself, you need to plan time away to tend to your own physical, social and emotional needs. If you don’t, you risk health-draining burnout. Churches, synagogues and volunteer groups may offer short-term relief. Adult day-care centers may be another option. The Alzheimer’s Association and Agency on Aging groups also provide respite-care resources. For overnight breaks, check with assisted-living facilities, which may offer furnished rooms, meals and nursing staff on a temporary basis.